January 30, 2014
BERLIN — It’s been a little over a month since German driving legend Michael Schumacher suffered severe trauma to his skull and brain in a ski accident on the slopes above Méribel, France. He has been in an artificially induced coma since then, though news came Thursday that doctors have finally begun the slow “waking up” process.
“We pray, we wish, we hope that a miracle comes to pass and the man who wakes up from the coma is the same man he was before the accident,” star driver Sebastian Vettel says.
But the healing process after such severe accidents depends on many different factors, and is unique to each individual. Outcomes are difficult even for attending physicians to predict.
Many others share the same fate as Schumacher, who is being treated at a hospital in Grenoble, France. In Germany alone, some 248,000 people a year suffer cranial trauma, and it is the major cause of death among those under 45.
In severe cases like Schumacher’s, intensive care specialists agree that an artificially induced coma is the best course of action. After such a violent fall, the brain swells the way any other body part would. And yet there isn’t room inside the skull for swelling, which traps blood vessels and endangers oxygen supply. Deprived of oxygen, more and more nerve cells die, and the risk of permanent damage increases.
Artificially induced coma — basically long-term narcosis — reduces the oxygen needs of nerve cells and hence reduces swelling. It also stabilizes circulation and prevents the patient from experiencing heavy levels of pain or anxiety that would keep the body in a permanent state of stress.
A rule of thumb among doctors is that induced comas should be maintained for as long as necessary, but no longer, so that the patient’s control over his body is restored quickly. “Medically, the goal is always to end artificially induced comas as soon as possible,” says Andreas Zieger of the Department of Special Needs Education and Rehabilitation at Oldenburg University. “It will only be kept up if there are major reasons to do so — for example, because the brain urgently requires support in order to heal.”
According to Zieger, a neurosurgeon, the longer a coma lasts the more severe the underlying reason for it — or the possibility of later complications arising. “The complication rate rises every day the patient spends in such a coma — which means the prognosis for the patient becomes less and less good,” he says. Some 40% to 50% of patients with severe head trauma in an artificially induced coma die in intensive care.
The other half of patients make it through, but many have to deal with considerable complications. “How damaged the brain is depends on what tissue was destroyed and to what extent,” says Claudia Spies, head of the anesthesiology clinic specializing in operative intensive medicine at Berlin’s Charité Hospital. “If, for example, there was a lot of bleeding on the right side of the brain, then you can count on decrease of function in the left-hand side of the body.”
Damage can’t be predicted
Doctors cannot, however, predict with any precision to what extent there will be bodily or cognitive damage, not least because swollen tissue may regenerate. Frequent consequences of severe head trauma are motor and speaking difficulties, but memory, concentration, and the speed of thought may also be affected. There are also often personality changes: Patients may become more aggressive, depressive, or experience mood swings.
Narcosis also has side effects, as do long periods spent lying in bed and artificial respiration, which can lead to thrombosis or infections like inflammation of the lungs. Long term, the immune system may be weakened, and there can be blood pressure, nerve and muscle issues, or long-lasting disturbances of consciousness and perception.
To avoid or at least minimize such effects, doctors try to mobilize and stabilize patients early on, Zieger says. “But the extent to which that is possible depends on the patient’s reactions.”
If the patient is in a relatively deep artificial coma, mobility will be limited to moving their arms and legs, or making fists with their hands. Later, the patient can be raised to a vertical position in bed. This has a positive effect on alertness, Zieger says. In cases of severe trauma, as soon as bleeding and swelling have substantially subsided, narcosis is reduced little by little and doctors work towards getting the patient to regain control of his body. Slowly the patient regains consciousness.
“In severe cases, waking comas are a kind of transitional phase between deep artificially induced coma and full consciousness,” Zieger explains. “A patient in a waking coma may breathe on their own, and can open their eyes but can’t focus them. They do not react to their surroundings.” Some, he adds, stay in this state for days, weeks, months, even years. Zieger recalls one case where the patient only emerged from a waking coma after 50 years.
“A friendly, trusted atmosphere with family members and positive feelings are, in my experience and in the light of recent research, very important in helping patients out of waking comas,” Zieger says.
Two further problems when patients wake up, says Claudia Spies, are withdrawal symptoms from the narcosis medication, which affect 60% of patients, and delirium that is marked by thought disturbances, memory and concentration problems, as well as character changes and delusions or aggressive behavior.
Delirium affects 50% to 80% of patients who regain consciousness and can result in many complications if they are not dealt with immediately. In cases of delirium, the risk of dying within the next six months is increased threefold.
A lot of patience is required to determine which residual effects will become permanent. It takes several months to establish what damage is irreversible and what the brain can compensate. According to Zieger, that is why “rehabilitation is started very early on,” and even in intensive care much importance is attached to stimulating the patient’s mobility of body and spirit.
Die Welt ("The World") is a German daily founded in Hamburg in 1946, and currently owned by the Axel Springer AG company, Europe's largest publishing house. Now based in Berlin, Die Welt is sold in more than 130 countries. A Sunday edition called Welt am Sonntag has been published since 1948.
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Once meant to protect the royal family, the century-old law has become a tool for the military-led government in Bangkok to stamp out all dissent. A new report outlines the abuses.
October 22, 2021
"We need to reform the institution of the monarchy in Thailand. It is the root of the problem." Those words, from Thai student activist Juthatip Sirikan, are a clear expression of the growing youth-led movement that is challenging the legitimacy of the government and demanding deep political changes in the Southeast Asian nation. Yet those very same words could also send Sirikan to jail.
Thailand's Criminal Code 'Lèse-Majesté' Article 112 imposes jail terms for defaming, insulting, or threatening the monarchy, with sentences of three to 15 years. This law has been present in Thai politics since 1908, though applied sparingly, only when direct verbal or written attacks against members of the royal family.
But after the May 2014 military coup d'état, Thailand experienced the first wave of lèse-majesté arrests, prosecutions, and detentions of at least 127 individuals arrested in a much wider interpretation of the law.
The recent report 'Second Wave: The Return of Lèse-Majesté in Thailand', documents how the Thai government has "used and abused Article 112 of the Criminal Code to target pro-democracy activists and protesters in relation to their online political expression and participation in peaceful pro-democracy demonstrations."
Criticism of any 'royal project'
The investigation shows 124 individuals, including at least eight minors, have been charged with lèse-majesté between November 2020 and August 2021. Nineteen of them served jail time. The new wave of charges is cited as a response to the rising pro-democracy protests across Thailand over the past year.
Juthatip Sirikan explains that the law is now being applied in such a broad way that people are not allowed to question government budgets and expenditure if they have any relationship with the royal family, which stifles criticism of the most basic government decision-making since there are an estimated 5,000 ongoing "royal" projects. "Article 112 of lèse-majesté could be the key (factor) in Thailand's political problems" the young activist argues.
In 2020 the Move Forward opposition party questioned royal spending paid by government departments, including nearly 3 billion baht (89,874,174 USD) from the Defense Ministry and Thai police for royal security, and 7 billion baht budgeted for royal development projects, as well as 38 planes and helicopters for the monarchy. Previously, on June 16, 2018, it was revealed that Thailand's Crown Property Bureau transferred its entire portfolio to the new King Maha Vajiralongkorn.
Protestors In Bangkok Call For Political Prisoner Release
Freedom of speech at stake
"Article 112 shuts down all freedom of speech in this country", says Sirikan. "Even the political parties fear to touch the subject, so it blocks most things. This country cannot move anywhere if we still have this law."
The student activist herself was charged with lèse-majesté in September 2020, after simply citing a list of public documents that refer to royal family expenditure. Sirikan comes from a family that has faced the consequences of decades of political repression. Her grandfather, Tiang Sirikhan was a journalist and politician who openly protested against Thailand's involvement in World War II. He was accused of being a Communist and abducted in 1952. According to Sirikhan's family, he was killed by the state.
The new report was conducted by The International Federation for Human Rights (FIDH), Thai Lawyer for Human Rights (TLHR), and Internet Law Reform Dialogue (iLaw). It accuses Thai authorities of an increasingly broad interpretation of Article 112, to the point of "absurdity," including charges against people for criticizing the government's COVID-19 vaccine management, wearing crop tops, insulting the previous monarch, or quoting a United Nations statement about Article 112.
Activist in front of democracy monument in Thailand.
Shift to social media
While in the past the Article was only used against people who spoke about the royals, it's now being used as an alibi for more general political repression — which has also spurred more open campaigning to abolish it. Sirikan recounts recent cases of police charging people for spreading paint near the picture of the king during a protest, or even just for having a picture of the king as phone wallpaper.
The more than a century-old law is now largely playing out online, where much of today's protest takes place in Thailand. Sirikan says people are willing to go further on social media to expose information such as how the king intervenes in politics and the monarchy's accumulation of wealth, information the mainstream media rarely reports on them.
Not surprisingly, however, social media is heavily monitored and the military is involved in Intelligence operations and cyber attacks against human rights defenders and critics of any kind. In October 2020, Twitter took down 926 accounts, linked to the army and the government, which promoted themselves and attacked political opposition, and this June, Google removed two Maps with pictures, names, and addresses, of more than 400 people who were accused of insulting the Thai monarchy. "They are trying to control the internet as well," Sirikan says. "They are trying to censor every content that they find a threat".
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